Annuity Information Request Form

Step 1 of 6

Personal information

Let's start with the basics.

Full legal name

Please enter your full legal name.

Date of birth

Please enter your date of birth.

Mailing address

Please enter your mailing address.

City

Required.

State

Required.

ZIP code

Required.

Phone number

Please enter a phone number.

Email address

Please enter a valid email address.

Marital status

Please select an option.

U.S. citizen?

Please select an option.

Step 2 of 6

Spouse or co-applicant

Only fill this in if a spouse or co-applicant will be included on the annuity. Otherwise, skip ahead.

Full legal name (optional)

Date of birth (optional)

Phone number (optional)

Email address (optional)

Step 3 of 6

Financial snapshot

General figures are fine — this helps us understand fit, not qualify you for anything.

Current employment status

Please select an option.

Expected / current retirement age

Please enter an age.

Approx. total investable assets

Please select a range.

Approx. annual household income

Please select a range.

Existing guaranteed income sources (Social Security, pension, etc.)

At tax time, do you typically get a refund or owe?

Usually get a refund Usually owe About even Not sure

Roughly how much, most years? (optional)

Step 4 of 6

Existing annuity or retirement contracts

Do you currently own an annuity?

Yes, I currently own one No, I do not

Purpose of this inquiry

Please select an option.

Step 5 of 6

Goals and risk tolerance

What are you hoping this annuity will do? (Select all that apply)

Guaranteed lifetime income Principal protection Growth potential Legacy / death benefit for heirs Long-term care coverage Tax-deferred growth

Amount you're considering placing into an annuity

Source of funds

When would you like income to begin?

How long can these funds stay invested before you need them?

Risk tolerance

Conservative — protect principal Moderate — some growth, limited downside Growth-oriented

Life insurance & long-term care

These often work alongside an annuity, and some products cover more than one of these needs at once. Answer what you can — "not sure" is a fine answer.

Do you currently have life insurance?

Yes No Not sure

Are you interested in reviewing life insurance options?

Yes No Maybe — tell me more

Do you currently have long-term care coverage? This covers extended care at home, in assisted living, or in a nursing facility — things standard health insurance and Medicare largely don't pay for.

Yes No Not sure

Have you thought about how a long-term care event would be paid for?

Yes, we have a plan We'd self-fund from savings No, haven't thought about it It worries me

Are you interested in reviewing long-term care options? Some annuities and life policies include a long-term care rider, so this can sometimes be handled inside what you're already considering.

Yes No Maybe — tell me more

Have you had a family experience with long-term care? (optional)

Step 6 of 6

Beneficiaries & final notes

Primary beneficiary name

Relationship

% share

Contingent beneficiary name (optional)

Relationship (optional)

% share (optional)

Additional notes or questions (optional)

Anything else you'd like information about? Optional — it just tells James what to bring up when you talk. He'll send you the right form for whatever you pick.

Medicare Individual/family health (ACA) Dental, vision & hearing Social Security analysis Nothing else right now

I authorize this information to be used to research and present annuity options on my behalf. I understand this form is not an application or purchase of any product.

By checking this box, I agree to receive text messages from JRB Insurance LLC about my appointments and insurance applications at the number provided. Consent is not a condition of purchase. Message frequency varies. Message and data rates may apply. Reply STOP to opt out or HELP for help. See our Privacy Policy and Terms.

Personal information

Spouse or co-applicant

Financial snapshot

Existing annuity or retirement contracts

Goals and risk tolerance

Life insurance & long-term care

Beneficiaries & final notes

Request received